Original article published here
*Please note: important terms used in this article, including PrEP, HIV, HIV Status, and U=U, have more information and links in the glossary at the end of the article.*
An important component of enjoying a good sexual health is the prevention of new HIV transmissions, something which is the combined responsibility of both HIV-negative people and people living with HIV (PLHIV) – that is, everyone’s responsibility! PLHIV can feel secure and confident that they are effectively unable to transmit HIV to their sexual partner/s with an Undetectable Viral Load (UVL) from taking daily antiretroviral medication. The roll-out of PrEP – that ‘little blue pill’ – to gay, bisexual and other homosexually active men in Perth over the last few years also gives a new tool for HIV-negative men to prevent HIV. This changing landscape of the way that HIV prevention is enacted does, however, produce some disagreement and debate, particularly between condoms and PrEP/UVL.
At M Clinic, we approach condoms, PrEP, and UVL, along with other risk reduction strategies, as various ‘tools’ within a toolbox. We support people to make informed decisions about their means of preventing HIV. Back in the 2009 ‘Toolbox: A Guide to Sexually Transmissible Infections for Men’ WA AIDS Council resource, the main tools included testing regularly for HIV and STIs, notifying partners of a positive STI so that they can test (contact tracing), getting vaccinated for Hepatitis A and B viruses, using condoms and water or silicone-based lubricants, and Post-Exposure Prophylaxis (PEP) in the event of a recent exposure. If we published a new edition of the Toolbox, we would keep all of these, but put PrEP and UVL to the forefront, as they are very effective and attractive new tools for preventing HIV transmission. The Ending HIV campaign also presents condoms, UVL, and PrEP in a similar way that we find appealing.
The most exciting part of the roll-out of PrEP has been that within the same timeframe, we have seen a significant drop in HIV notifications (the amount of new HIV diagnosed) in Western Australia. While we cannot prove it was due to PrEP, we believe the two are linked.
WA has seen a 50% reduction (68 in 2016 down to 34 in 2017) in HIV notifications for men who have sex with men (see 2017 third quarter STI and BBV report). 76% of these 34 people newly diagnosed with HIV reported acquiring HIV within Australia. In understanding the number of transmissions, it is important to compare it to an average over a longer period time. Between 2012-2016, the average number of HIV notifications per year in men who have sex with men was 67 (see 2016 annual report). So a total of 34 in one year is a really significant shift in comparison to the longer trend! Of course, this early data needs to be interpreted with some caution, and a true reduction in HIV notifications requires a consistent reduction over a larger number of years, which we will be carefully observing.
Why have HIV notifications been going down?
It is an exciting trend, and we want to keep the momentum going. But why are HIV notifications reducing? I speculate a few different reasons that may be occurring concurrently:
- The drop in HIV notifications in NSW and other eastern states, which is attributed to PrEP and increased testing. Many people travel between different Australian states, and any increase or reduction in other parts of Australia will impact WA.
- The increased availability and promotion of PrEP in WA. South Terrace Clinic, Royal Perth Hospital Ainslie House, and GP on Beaufort began prescribing PrEP at different times in 2015, and M Clinic has worked alongside them to educate people about PrEP, and to encourage and refer people at risk of acquiring HIV to consider accessing PrEP. This process has relied upon accessing a doctor’s prescription and then personally importing medication, which back in 2015 cost approximately $70-80/month, but is now as low as $31/month. Many people still access PrEP this way.
- Increased testing for HIV. M Clinic alone has tested over 5000 different people at least once for HIV since we opened in 2010. Many clients return to us for regular testing. The sooner that a person learns their positive HIV status, the sooner they can go on treatment, become undetectable, and prevent onward transmission of HIV.
To summarise, a combination of testing and supporting people to get onto HIV treatment, along with the increased provision of PrEP function together to reduce new HIV infections. As the PrEPIT-WA trial continues, we should expect a continuation of this trend, and perhaps even a further reduction in new HIV notifications.
Where to From Here – Promoting Great Sexual Health
A challenging aspect of this new landscape of HIV prevention is that the complex array of knowledge and concepts available to prevent HIV requires comprehensive education, and nuanced ways of publicly presenting information in a succinct and accessible way to different populations. Sexual health and HIV prevention have become more complicated, and although our main emphasis at M Clinic is on HIV/STI testing, we cannot address HIV prevention and good sexual health without including discussions about sexuality, gender, alcohol/drug usage, mental health, and enthusiastic consent. All of this requires the promotion of a person-centred, comfortable, and sex-positive approach by all of our staff and volunteers.
So while new methods of preventing HIV are at our disposal, the key ingredients remain the same. As one our Clinical Nurse Consultants, Garry Kuchel reflects in an article for the International AIDS Society,
“The M Clinic has undergone a massive evolution from where it started to where it is now, and nobody anticipated the success of the clinic. The primary aim is screening and education, but we also provide treatment for STIs, including syphilis, gonorrhoea and chlamydia. The most important part of the service is that we have a very strong culture of no judgement, no stigma and no discrimination. That is key for all of the people working in the clinic.”
However the technologies and mechanisms may change, we continue to endeavour to work as a community to promote great sexual health – whatever that looks like for you!
How to get PrEP
In Western Australia, there are two main ways to get onto PrEP:
- PrEPIT-WA (study trial)
- Personal Importation (with a script from a doctor)
- Also – read below about the Pharmaceutical Benefits Advisory Committee (PBAC) recommendation to list PrEP on the Pharmaceutical Benefits Scheme (PBS).
PrEPIT-WA is a study run by the Kirby Institute, University of New South Wales, funded by the Western Australian (WA) Government, in collaboration with a number of partners, including sexual health services and clinics. PrEPIT-WA aims to assess the impact of the rapid expansion in access to PrEP amongst those at highest risk of acquiring HIV, in particular, if it will lead to a drop in new HIV infections. The study will see 2,000 people at high risk of acquiring HIV enrolled in the study as efficiently as possible.
PrEPIT-WA is a criteria-based access program, which means eligibility for the study will be determined on the basis of HIV risk criteria. The aim is to rapidly enrol eligible people and follow them for up to two years while they take PrEP.
It is important to note that this study is not evaluating the effectiveness of PrEP itself, as this has already been demonstrated in a number of studies. Rather, this study is investigating how it is best implemented to maximise its impact at a population level.
There are 4 locations in Perth enrolling people onto the PrEPIT-WA trial. People living in regional parts of Western Australia are able to participate through tele-health arrangements with Royal Perth Hospital Sexual Health Service. People who live regionally and would like to discuss enrolment, should contact Mary at the Royal Perth Hospital Sexual Health Service on (08) 9224 3197 (regional only).
|Can anyone attend?||Consult Fees?||Medicare Required?||Contact Details|
|M Clinic||Only for men who have sex with other men, including trans and non-binary people.||No||Yes||(08) 9227 0734
548 Newcastle St, West Perth WA 6005
|GP on Beaufort||Yes||Yes||Yes||(08) 9262 8600
691 Beaufort St, Mt Lawley WA 6050
|South Terrace Clinic||Yes||No||No||(08) 9431 2149
A Block, Fremantle Hospital Alma St, Fremantle WA 6160
|Royal Perth Hospital Sexual Health Service||Yes||No||No||(08) 9224 2178
Level 4, Ainslie House
48 Murray St, Perth WA 6000
For more information:
Call: the WA PrEP Info Line – 1800 671 130.
Please note that even with PBS-listing, the PrEPIT-WA Trial will continue unchanged.
Personal Importation – $31/month OR Free
Given that PrEP is not yet on the Pharmaceutical Benefits Scheme (PBS) in Australia, purchasing PrEP with a script within Australia is very expensive. However, it is completely legal (see TGA guidelines) for someone to personally import medication, and this is how a majority of Australians outside of study trials have been accessing PrEP.
Before you can personally import your medication, you need to get a doctor’s prescription for PrEP, which includes testing for HIV, testing kidney function, and a routine STI screen. Once you have your script, you can head over to PAN (PrEP Access Now) or PrEP.Global to pick an online pharmacy to order from. After ordering, the medication will usually arrive at your door within a week or two.
You repeat this process every 3 months to keep up your medication.
If cost is a barrier, you may be eligible for free PrEP – which still requires a doctor’s prescription, but instead of paying for it you apply for a coupon through M Clinic. These coupons are provided by Green Cross Pharmacy, with 10% of their overall sales contributing to providing free PrEP. If your application is successful (a script + some proof/description of financial situation, including healthcare/concession card or student card), then you are given a code to pay for your 3 months of free PrEP via Green Cross Pharmacy. You can apply for this every time you need more medication.
PrEP on the PBS
On Friday the 9th of February 2018, Truvada as PrEP (along with some generic-brand equivalents) were recommended by the Pharmaceutical Benefits Advisory Committee (PBAC) to be put onto the Pharmaceutical Benefits Scheme (PBS). This is an important step in seeing PrEP available on the PBS, and it is expected that PrEP will be available through the PBS by mid-2018.
This means that after acquiring a script from a GP for PrEP, individuals can go to a local pharmacy with their script and purchase their PrEP through a small co-payment. A co-payment of $39.50/month or $6.40/month with concession card is expected. This means that people can locally and reliably access PrEP on the same day as prescription.
Without concession, the price will still be cheaper through personal importation. However, we are excited to see expanded choice in accessing PrEP, along with the increase of legitimacy that PrEP works, which is gained through PBAC recommendation.
Please note that even with PBS-listing, the PrEPIT-WA Trial will continue unchanged.
PrEP: The Final Word
There are numerous reasons that someone might go on PrEP. Some people go on PrEP with the intention to stop using condoms (or because they are not using them anyway), some people go on PrEP because even though they use condoms for anal sex every time, they are still afraid of HIV, and others decide to go on PrEP because they want to feel empowered about their sexual decision-making. At M Clinic, we support the decisions that people want to make about their body, and encourage people to discuss their sexual negotiations with their partner/s.
These advancements in HIV prevention offered by PrEP and UVL are exciting because they offer new ways for people to negotiate different kinds of sex, and to be confident that HIV will not be transmitted. As Grant and Koester remark in a 2016 journal article,
“Although the intended purpose of PrEP was to lower the incidence of HIV infection, PrEP users report being attracted to benefits that are salient, affective, and occur in the present. Such PrEP benefits include more pleasure, more intimacy, stronger relationships, feeling safer, less stigma, feeling empowered by planning for sexual and partnership goals, and ability to plan families.”
So in 2018 we encourage you to continue taking charge of your sexual health. Get tested, figure out how you and your partner/s want to prevent HIV transmission, and enjoy your sexuality!
PrEP – Pre-exposure prophylaxis is medication that a HIV-negative person can take on a daily basis to effectively prevent HIV transmission. Part of going on PrEP involves a doctor prescription and regular 3 monthly testing for HIV and other STIs, along with monitoring kidney function. See ‘availability of PrEP’ for more information on how to get onto PrEP in WA.
For more information on PrEP – see PAN (PrEP Access Now)
HIV – Human Immunodeficiency Virus is an incurable, but medically manageable illness. Transmitted between humans only, usually through condomless anal or vaginal sex, or sharing needles intravenously, HIV can be deadly if left unmanaged (Leading to ‘AIDS’ – Acquired Immune Deficiency Syndrome). HIV should not be confused with AIDS. People who test positive for HIV can start antiretroviral treatment (usually one pill a day, with minimal or no side-effects) and live a healthy and otherwise normal life. If they are taking their medication every day, they usually reach an ‘undetectable viral load’ (See U=U). The main difficulties that people living with HIV in Australia experience are around stigma, particularly around sex and dating, but also particular legal barriers, such as difficulties in acquiring permanent residency in Australia.
HIV Status – You can only know your HIV status from testing. If you last tested negative (no HIV), you need to consider if you were at-risk in the 6 weeks prior to the test (window period where HIV may not be accurately detected), and if you have had any risk since your last test. A common factor in new infections is transmission from someone who has just recently acquired HIV, as a person is most infectious in the first months after acquiring HIV (when they are unlikely to know that they have it!)
For more information on where to get tested across Australia – see The Drama Down Under (gay/bi men)
U=U – Undetectable = Untransmittable. International HIV/AIDS organisations, scientific bodies, and other groups committed to ending HIV/AIDS have endorsed the message of U=U. If a HIV-positive person takes their HIV medication every day, and may therefore have an ‘undetectable viral load’ (sometimes called ‘treatment as prevention), they are effectively unable to transmit HIV to their sexual partners, regardless of condom usage or PrEP. HIV has not been transmitted from a person with an undetectable viral load in any study setting observing treatment as prevention.
For more information on U=U – see Prevention Access Campaign.
Anthony K J Smith
M Clinic Peer Educator